Deficiency Records for Hagerstown Healthcare Center

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Updated as of March 01, 2024

A list of the most recent deficiencies for Hagerstown Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Health 2023-12-22 2024-02-02 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-12-22 2024-02-02 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-12-22 2024-02-02 Y
Respond appropriately to all alleged violations. Health 2023-12-22 2024-02-02 Y
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2023-12-22 2024-02-02 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-12-22 2024-02-02 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-08-21 2023-09-20 Y
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2023-01-13 2023-04-24 Y
Keep residents' personal and medical records private and confidential. Health 2023-01-13 2023-04-24 Y
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Health 2023-01-13 2023-04-24 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2023-01-13 2023-04-24 Y
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2023-01-13 2023-04-24 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2023-01-13 2023-04-24 Y
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. Health 2023-01-13 2023-04-24 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2023-01-13 2023-04-24 Y
Provide and implement an infection prevention and control program. Health 2023-01-13 2023-04-24 Y
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. Health 2023-01-13 2023-02-27 Y
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Health 2023-01-13 2023-02-27 Y
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Health 2023-01-13 2023-02-27 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-01-13 2023-02-27 Y
Protect each resident from the wrongful use of the resident's belongings or money. Health 2023-01-13 2023-02-27 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2023-01-13 2023-02-27 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-01-13 2023-02-27 Y
Respond appropriately to all alleged violations. Health 2023-01-13 2023-02-27 Y
Provide doctor's orders for the resident's immediate care at the time the resident was admitted. Health 2023-01-13 2023-02-27 Y
Ensure each resident receives an accurate assessment. Health 2023-01-13 2023-02-27 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-01-13 2023-02-27 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-01-13 2023-02-27 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-01-13 2023-02-27 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2023-01-13 2023-02-27 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-01-13 2023-02-27 Y
Provide safe, appropriate pain management for a resident who requires such services. Health 2023-01-13 2023-02-27 Y
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2023-01-13 2023-02-27 Y
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Health 2023-01-13 2023-02-27 Y
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Health 2023-01-13 2023-02-27 Y
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. Health 2023-01-13 2023-02-27 Y
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2023-01-13 2023-02-27 Y
Ensure medication error rates are not 5 percent or greater. Health 2023-01-13 2023-02-27 Y
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Health 2023-01-13 2023-02-27 Y
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2023-01-13 2023-02-27 Y
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. Health 2023-01-13 2023-02-27 Y
Have a plan that describes the process for conducting QAPI and QAA activities. Health 2023-01-13 2023-02-27 Y
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2022-12-14 2023-01-18 Y
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2022-12-14 2023-01-18 Y
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-12-14 2023-01-18 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2021-11-03 2021-12-17 Y
Reasonably accommodate the needs and preferences of each resident. Health 2021-11-03 2021-12-17 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2021-11-03 2021-12-17 Y
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Health 2021-11-03 2021-12-17 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2021-11-03 2021-12-17 Y
Protect each resident from the wrongful use of the resident's belongings or money. Health 2021-11-03 2021-12-17 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2021-11-03 2021-12-17 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2021-11-03 2021-12-17 Y
Respond appropriately to all alleged violations. Health 2021-11-03 2021-12-17 Y
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2021-11-03 2021-12-17 Y
Prepare residents for a safe transfer or discharge from the nursing home. Health 2021-11-03 2021-12-17 Y
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. Health 2021-11-03 2021-12-17 Y
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2021-11-03 2021-12-17 Y
Ensure each resident receives an accurate assessment. Health 2021-11-03 2021-12-17 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2021-11-03 2021-12-17 Y
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2021-11-03 2021-12-17 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2021-11-03 2021-12-17 Y
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Health 2021-11-03 2021-12-17 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-11-03 2021-12-17 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2021-11-03 2021-12-17 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-11-03 2021-12-17 Y
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2021-11-03 2021-12-17 Y
Provide enough food/fluids to maintain a resident's health. Health 2021-11-03 2021-12-17 Y
Provide safe, appropriate pain management for a resident who requires such services. Health 2021-11-03 2021-12-17 Y
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Health 2021-11-03 2021-12-17 Y
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2021-11-03 2021-12-17 Y
Post nurse staffing information every day. Health 2021-11-03 2021-12-17 Y
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. Health 2021-11-03 2021-12-17 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2021-11-03 2021-12-17 Y
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2021-11-03 2021-12-17 Y
Ensure that residents are free from significant medication errors. Health 2021-11-03 2021-12-17 Y
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Health 2021-11-03 2021-12-17 Y
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2021-11-03 2021-12-17 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2021-11-03 2021-12-17 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2021-11-03 2021-12-17 Y
Provide and implement an infection prevention and control program. Health 2021-11-03 2021-12-17 Y
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2021-11-03 2021-12-17 Y
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Health 2021-11-03 2021-12-17 Y
Put firmly secured handrails on each side of hallways. Health 2021-11-03 2021-12-17 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2019-04-08 2019-08-27 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2019-04-08 2019-08-27 N
Prepare residents for a safe transfer or discharge from the nursing home. Health 2019-04-08 2019-08-27 N
Ensure each resident receives an accurate assessment. Health 2019-04-08 2019-08-27 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2019-04-08 2019-08-27 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2019-04-08 2019-08-27 N
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2019-04-08 2019-08-27 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2019-04-08 2019-08-27 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2019-04-08 2019-08-27 N
Allow resident to participate in the development and implementation of his or her person-centered plan of care. Health 2019-04-08 2019-06-24 N
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2019-04-08 2019-06-24 N
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Health 2019-04-08 2019-06-24 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2019-04-08 2019-06-24 N
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2019-04-08 2019-06-24 N
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Health 2019-04-08 2019-06-24 N
Respond appropriately to all alleged violations. Health 2019-04-08 2019-06-24 N
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Health 2019-04-08 2019-06-24 N
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. Health 2019-04-08 2019-06-24 N
Provide doctor's orders for the resident's immediate care at the time the resident was admitted. Health 2019-04-08 2019-06-24 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2019-04-08 2019-06-24 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2019-04-08 2019-06-24 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2019-04-08 2019-06-24 N
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. Health 2019-04-08 2019-06-24 N
Provide activities to meet all resident's needs. Health 2019-04-08 2019-06-24 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2019-04-08 2019-06-24 N
Assist a resident in gaining access to vision and hearing services. Health 2019-04-08 2019-06-24 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2019-04-08 2019-06-24 N
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2019-04-08 2019-06-24 N
Provide enough food/fluids to maintain a resident's health. Health 2019-04-08 2019-06-24 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2019-04-08 2019-06-24 N
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. Health 2019-04-08 2019-06-24 N
Post nurse staffing information every day. Health 2019-04-08 2019-06-24 N
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. Health 2019-04-08 2019-06-24 N
Ensure medication error rates are not 5 percent or greater. Health 2019-04-08 2019-06-24 N
Ensure that residents are free from significant medication errors. Health 2019-04-08 2019-06-24 N
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Health 2019-04-08 2019-06-24 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2019-04-08 2019-06-24 N
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Health 2019-04-08 2019-06-24 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2019-04-08 2019-06-24 N
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Health 2019-04-08 2019-06-24 N
Provide and implement an infection prevention and control program. Health 2019-04-08 2019-06-24 N
Make sure that a working call system is available in each resident's bathroom and bathing area. Health 2019-04-08 2019-06-24 N
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Health 2019-04-08 2019-06-24 N
Meet other general requirements. Fire Safety 2019-04-10 2019-05-31 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2019-04-10 2019-05-31 N
Have stairways and smokeproof enclosures used as exits that meet safety requirements. Fire Safety 2019-04-10 2019-05-31 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2019-04-10 2019-05-31 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2019-04-10 2019-05-31 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2019-04-10 2019-05-31 N
Install properly constructed and protected linen or trash chutes. Fire Safety 2019-04-10 2019-05-31 N
Have proper medical gas storage and administration areas. Fire Safety 2019-04-10 2019-05-31 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2017-10-30 2017-12-14 N
Ensure proper usage of power strips and extension cords. Fire Safety 2017-10-30 2017-12-14 N
Have proper medical gas storage and administration areas. Fire Safety 2017-10-30 2017-12-14 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2017-10-26 2017-12-04 N
Provide housekeeping and maintenance services. Health 2017-10-26 2017-12-04 N
Maintain comfortable and safe temperature levels. Health 2017-10-26 2017-12-04 N
Ensure each resident receives an accurate assessment by a qualified health professional. Health 2017-10-26 2017-12-04 N
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2017-10-26 2017-12-04 N
Allow residents the right to participate in the planning or revision of care and treatment. Health 2017-10-26 2017-12-04 N
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Health 2017-10-26 2017-12-04 N
Post nurse staffing information/data on a daily basis. Health 2017-10-26 2017-12-04 N
Store, cook, and serve food in a safe and clean way. Health 2017-10-26 2017-12-04 N
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Health 2017-10-26 2017-12-04 N
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Health 2017-10-26 2017-12-04 N
Have a program that investigates, controls and keeps infection from spreading. Health 2017-10-26 2017-12-04 N
Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Health 2017-10-26 2017-12-04 N
Keep accurate, complete and organized clinical records on each resident that meet professional standards. Health 2017-10-26 2017-12-04 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Health 2017-10-26 2017-12-04 N
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Health 2016-09-20 2016-11-14 N
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Health 2016-09-20 2016-11-14 N
Reasonably accommodate the needs and preferences of each resident. Health 2016-09-20 2016-11-14 N
Provide housekeeping and maintenance services. Health 2016-09-20 2016-11-14 N
Conduct initial and periodic assessments of each resident's functional capacity. Health 2016-09-20 2016-11-14 N
Ensure each resident receives an accurate assessment by a qualified health professional. Health 2016-09-20 2016-11-14 N
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2016-09-20 2016-11-14 N
Allow residents the right to participate in the planning or revision of care and treatment. Health 2016-09-20 2016-11-14 N
Provide care by qualified persons according to each resident's written plan of care. Health 2016-09-20 2016-11-14 N
Provide necessary care and services to maintain or improve the highest well being of each resident . Health 2016-09-20 2016-11-14 N
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Health 2016-09-20 2016-11-14 N
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Health 2016-09-20 2016-11-14 N
Have enough nurses to care for every resident in a way that maximizes the resident's well being. Health 2016-09-20 2016-11-14 N
Provide a tasty and well-balanced diet that meets the nutritional needs of each resident. Health 2016-09-20 2016-11-14 N
Store, cook, and serve food in a safe and clean way. Health 2016-09-20 2016-11-14 N
Give or get specialized rehabilitative services per the patient's assessment or plan of care. Health 2016-09-20 2016-11-14 N
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Health 2016-09-20 2016-11-14 N
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Health 2016-09-20 2016-11-14 N
Have a program that investigates, controls and keeps infection from spreading. Health 2016-09-20 2016-11-14 N
Keep all essential equipment working safely. Health 2016-09-20 2016-11-14 N
Have enough backup water supply for essential areas of the nursing home. Health 2016-09-20 2016-11-14 N
Put firmly secured handrails on each side of hallways. Health 2016-09-20 2016-11-14 N
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Health 2016-09-20 2016-11-14 N
1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. Health 2016-09-20 2016-11-14 N
Keep accurate, complete and organized clinical records on each resident that meet professional standards. Health 2016-09-20 2016-11-14 N
Walls that prevent smoke from passing through and would resist fire for at least one hour. Fire Safety 2016-09-22 2016-10-24 N
Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. Fire Safety 2016-09-22 2016-10-24 N
An externally vented heating system. Fire Safety 2016-09-22 2016-10-24 N